The treatment of mentally disordered offenders.

Abstract

However narrowly defined, mentally disordered offenders (MDOs) are heterogeneous in demographics, diagnoses, offense characteristics, risk, and clinical needs. Treatment planning for MDOs should begin with an assessment of risk of future violent behavior in the community and risk of violence toward self or others inside an institution. Purposes of treatment among MDOs include treatments both to reduce risk of future violence and to alleviate the mental disorder. Relevant outcome measures include criminal and violent behavior, psychiatric symptomatology, admission to correctional or psychiatric facility, and quality of life. Clinical problems include aggression and problems of institutional management, criminal propensity, life skills deficits, substance abuse, active psychotic symptoms, social withdrawal, and depression. Because evidence relating them to risk of future violence is highest for the first 4 problems, it is argued that inpatient treatments should especially target them. Whenever risk levels and legal circumstances permit, community treatment is to be preferred. Sex offenders are discussed as a group for whom specialized services are indicated. Relapse prevention and program development evaluation are recommended methods for guiding treatment planning at both individual and system levels. Obstacles to implementation of empirically based treatments are discussed, as are suggestions for overcoming such obstacles. Finally, promising directions for future research are suggested. The term mentally disordered offender encompasses a heterogeneous and poorly defined group. In its narrowest interpretation, the category is a legal one and includes insanity acquittees, persons found guilty but mentally ill, persons found unfit to stand trial, mentally disordered sex offenders, sexual predators, and prisoners transferred to mental health facilities. In a 1978 survey (Monahan & Steadman, 1983), 7% of all the offenders detained in the United States were officially designated as mentally disordered. Of these, 8% were insanity acquittees, 32% were incompetent to stand trial, 6% were mentally disordered sex offenders, and the majority (54%) were convicted prisoners who had been transferred to mental health facilities. By any definition, the overwhelming majority of mentally disordered offenders are men (e.g., Menzies, Chunn, & Webster, 1992; Steadman & Halfon, 1971). Even in its narrow interpretation, however, this population includes a diverse group with a wide range of treatment needs. Most would concede that the true number of mentally disordered offenders is many times higher than that described above. Studies of the prevalence of mental disorder among incarcerated offenders reveal a surprisingly high prevalence. In one study (Hodgins & Cotr, 1990), which used the Diagnostic Interview Schedule (Robins, Helzer, Croughan, & Ratcliff, 1981) to establish diagnoses, only 5% of penitentiary inmates in one Canadian province were found not to have a mental